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Akamine MAV, Ferreira Soares BMA, Telles JPM, Cicupira Rodrigues de Assis A, Rodriguez GNV, Soares PR, Chalela WA, Scudeler TL. Role of Dapagliflozin in Ischemic Preconditioning in Patients with Symptomatic Coronary Artery Disease-DAPA-IP Study Protocol. Pharmaceuticals (Basel) 2024; 17:920. [PMID: 39065769 PMCID: PMC11280174 DOI: 10.3390/ph17070920] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/27/2024] [Revised: 07/05/2024] [Accepted: 07/07/2024] [Indexed: 07/28/2024] Open
Abstract
Background: Ischemic preconditioning (IP) is a powerful cellular protection mechanism. The cellular pathways underlying IP are extremely complex and involve the participation of cell triggers, intracellular signaling pathways, and end-effectors. Experimental studies have shown that sodium-glucose transport protein 2 (SGLT2) inhibitors promote activation of 5'-adenosine monophosphate (AMP)-activated protein kinase (AMPK), the main regulator of adenosine 5'-triphosphate homeostasis and energy metabolism in the body. Despite its cardioprotective profile demonstrated by numerous clinical trials, the results of studies on the action of SGLT2 inhibitors in IP are scarce. This study will investigate the effects of dapagliflozin on IP in patients with coronary artery disease (CAD). Methods: The study will include 50 patients with multivessel CAD, ischemia documented by stress testing, and preserved left ventricular ejection fraction (LVEF). Patients will undergo four exercise tests, the first two with a time interval of 30 min between them after washout of cardiovascular or hypoglycemic medications and the last two after 7 days of dapagliflozin 10 mg once a day, also with a time interval of 30 min between them. Discussion: The role of SGLT2 inhibitors on IP is not clearly established. Several clinical trials have shown that SGLT2 inhibitors reduce the occurrence cardiovascular events, notably heart failure. However, such studies have not shown beneficial metabolic effects of SGLT2 inhibitors, such as reducing myocardial infarction or stroke. On the other hand, experimental studies with animal models have shown the beneficial effects of SGLT2 inhibitors on IP, a mechanism that confers cardiac and vascular protection from subsequent ischemia-reperfusion (IR) injury. This is the first clinical study to evaluate the effects of SGLT2 inhibitors on IP, which could result in an important advance in the treatment of patients with stable CAD.
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Affiliation(s)
| | | | | | | | | | | | | | - Thiago Luis Scudeler
- Instituto do Coração (InCor), Hospital das Clínicas da Faculdade de Medicina da Universidade de São Paulo, Av. Dr. Enéas de Carvalho Aguiar, 44, Cerqueira César, São Paulo 05403-000, Brazil; (M.A.V.A.); (B.M.A.F.S.); (J.P.M.T.); (A.C.R.d.A.); (G.N.V.R.); (P.R.S.); (W.A.C.)
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2
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Morrow AJ, Ford TJ, Mangion K, Kotecha T, Rakhit R, Galasko G, Hoole S, Davenport A, Kharbanda R, Ferreira VM, Shanmuganathan M, Chiribiri A, Perera D, Rahman H, Arnold JR, Greenwood JP, Fisher M, Husmeier D, Hill NA, Luo X, Williams N, Miller L, Dempster J, Macfarlane PW, Welsh P, Sattar N, Whittaker A, Connachie AM, Padmanabhan S, Berry C. Rationale and design of the Medical Research Council's Precision Medicine with Zibotentan in Microvascular Angina (PRIZE) trial. Am Heart J 2020; 229:70-80. [PMID: 32942043 PMCID: PMC7674581 DOI: 10.1016/j.ahj.2020.07.007] [Citation(s) in RCA: 36] [Impact Index Per Article: 9.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/12/2020] [Accepted: 07/08/2020] [Indexed: 01/09/2023]
Abstract
Microvascular angina is caused by cardiac small vessel disease, and dysregulation of the endothelin system is implicated. The minor G allele of the non-coding single nucleotide polymorphism (SNP) rs9349379 enhances expression of the endothelin 1 gene in human vascular cells, increasing circulating concentrations of ET-1. The prevalence of this allele is higher in patients with ischemic heart disease. Zibotentan is a potent, selective inhibitor of the ETA receptor. We have identified zibotentan as a potential disease-modifying therapy for patients with microvascular angina. METHODS: We will assess the efficacy and safety of adjunctive treatment with oral zibotentan (10 mg daily) in patients with microvascular angina and assess whether rs9349379 (minor G allele; population prevalence ~36%) acts as a theragnostic biomarker of the response to treatment with zibotentan. The PRIZE trial is a prospective, randomized, double-blind, placebo-controlled, sequential cross-over trial. The study population will be enriched to ensure a G-allele frequency of 50% for the rs9349379 SNP. The participants will receive a single-blind placebo run-in followed by treatment with either 10 mg of zibotentan daily for 12 weeks then placebo for 12 weeks, or vice versa, in random order. The primary outcome is treadmill exercise duration using the Bruce protocol. The primary analysis will assess the within-subject difference in exercise duration following treatment with zibotentan versus placebo. CONCLUSION: PRIZE invokes precision medicine in microvascular angina. Should our hypotheses be confirmed, this developmental trial will inform the rationale and design for undertaking a larger multicenter trial.
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Affiliation(s)
- Andrew J Morrow
- British Heart Foundation Glasgow Cardiovascular Research Centre, Institute of Cardiovascular and Medical Sciences, University of Glasgow, Glasgow, United Kingdom
| | - Thomas J Ford
- British Heart Foundation Glasgow Cardiovascular Research Centre, Institute of Cardiovascular and Medical Sciences, University of Glasgow, Glasgow, United Kingdom; University of New South Wales, Sydney, Australia
| | - Kenneth Mangion
- British Heart Foundation Glasgow Cardiovascular Research Centre, Institute of Cardiovascular and Medical Sciences, University of Glasgow, Glasgow, United Kingdom
| | - Tushar Kotecha
- Royal Free Hospital, Royal Free London NHS Foundation Trust London, United Kingdom
| | - Roby Rakhit
- Royal Free Hospital, Royal Free London NHS Foundation Trust London, United Kingdom
| | - Gavin Galasko
- Lancashire Cardiac Centre, Blackpool Teaching Hospitals NHS Foundation Trust, Blackpool, United Kingdom
| | - Stephen Hoole
- Department of Interventional Cardiology, Royal Papworth Hospital, Cambridge, United Kingdom
| | - Anthony Davenport
- Experimental Medicine and Immunotherapeutics, University of Cambridge, Cambridge, United Kingdom
| | - Rajesh Kharbanda
- Division of Cardiovascular Medicine, Radcliffe Department of Medicine, British Heart Foundation Centre of Research Excellence, NIHR Oxford Biomedical Research Centre, University of Oxford, John Radcliffe Hospital, Oxford, United Kingdom; Department of Cardiology, Oxford University Hospitals NHS Foundation Trust, John Radcliffe Hospital, Oxford, United Kingdom
| | - Vanessa M Ferreira
- Division of Cardiovascular Medicine, Radcliffe Department of Medicine, British Heart Foundation Centre of Research Excellence, NIHR Oxford Biomedical Research Centre, University of Oxford, John Radcliffe Hospital, Oxford, United Kingdom
| | - Mayooran Shanmuganathan
- Division of Cardiovascular Medicine, Radcliffe Department of Medicine, British Heart Foundation Centre of Research Excellence, NIHR Oxford Biomedical Research Centre, University of Oxford, John Radcliffe Hospital, Oxford, United Kingdom
| | - Amedeo Chiribiri
- Division of Imaging Sciences, Guy's and St Thomas' Hospital NHS Foundation Trust, London, United Kingdom
| | - Divaka Perera
- School of Cardiovascular Medicine and Sciences, King's College London, London, United Kingdom
| | - Haseeb Rahman
- School of Cardiovascular Medicine and Sciences, King's College London, London, United Kingdom
| | - Jayanth R Arnold
- Department of Cardiovascular Sciences, Glenfield Hospital, Leicester, United Kingdom
| | - John P Greenwood
- Leeds University and Leeds Teaching Hospitals NHS Trust, Leeds, United Kingdom
| | - Michael Fisher
- Liverpool University and Liverpool University Hospitals NHS Foundation Trust, Liverpool, United Kingdom
| | - Dirk Husmeier
- School of Mathematics & Statistics, University of Glasgow, Glasgow, United Kingdom
| | - Nicholas A Hill
- School of Mathematics & Statistics, University of Glasgow, Glasgow, United Kingdom
| | - Xiaoyu Luo
- School of Mathematics & Statistics, University of Glasgow, Glasgow, United Kingdom
| | - Nicola Williams
- Department of Clinical Genetics, Queen Elizabeth University Hospital, Glasgow, United Kingdom
| | - Laura Miller
- Department of Clinical Genetics, Queen Elizabeth University Hospital, Glasgow, United Kingdom
| | - Jill Dempster
- British Heart Foundation Glasgow Cardiovascular Research Centre, Institute of Cardiovascular and Medical Sciences, University of Glasgow, Glasgow, United Kingdom
| | - Peter W Macfarlane
- British Heart Foundation Glasgow Cardiovascular Research Centre, Institute of Cardiovascular and Medical Sciences, University of Glasgow, Glasgow, United Kingdom
| | - Paul Welsh
- British Heart Foundation Glasgow Cardiovascular Research Centre, Institute of Cardiovascular and Medical Sciences, University of Glasgow, Glasgow, United Kingdom
| | - Naveed Sattar
- British Heart Foundation Glasgow Cardiovascular Research Centre, Institute of Cardiovascular and Medical Sciences, University of Glasgow, Glasgow, United Kingdom
| | - Andrew Whittaker
- Emerging Innovations Unit, Discovery Sciences, R&D, AstraZeneca, Cambridge, United Kingdom
| | - Alex Mc Connachie
- Robertson Centre for Biostatistics, Institute of Health and Wellbeing, University of Glasgow, Glasgow, United Kingdom
| | - Sandosh Padmanabhan
- British Heart Foundation Glasgow Cardiovascular Research Centre, Institute of Cardiovascular and Medical Sciences, University of Glasgow, Glasgow, United Kingdom
| | - Colin Berry
- British Heart Foundation Glasgow Cardiovascular Research Centre, Institute of Cardiovascular and Medical Sciences, University of Glasgow, Glasgow, United Kingdom.
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Rezende PC, Ribas FF, Serrano CV, Hueb W. Clinical significance of chronic myocardial ischemia in coronary artery disease patients. J Thorac Dis 2019; 11:1005-1015. [PMID: 31019790 DOI: 10.21037/jtd.2019.02.85] [Citation(s) in RCA: 20] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/11/2023]
Abstract
Myocardial ischemia is considered the cornerstone of the treatment of patients with coronary artery disease (CAD). Although the deleterious effects of myocardial infarction, the maximum expression of ischemia, have been extensively studied and described, the clinical effects of chronic, documented myocardial ischemia are not completely clarified. The first studies that compared therapies for coronary disease focused on the presence of anatomical features and assessed ischemia based on the interpretation of the findings of obstructive atherosclerotic lesions. They suggested that revascularization interventions did not confer any clinical advantage over medical therapy (MT), in terms of cardiac or overall death. Other retrospective studies that were dedicated to assessing the impact of documented stress-induced ischemia on cardiovascular outcomes have suggested a prognostic impact of chronic ischemia. However, this has been questioned in recent studies. Moreover, the previous understanding that chronic ischemia could lead to worsening of ventricular function was not confirmed in a recent study. Thus, the prognostic significance of stress-induced ischemia has been questioned. Regarding treatment options, although some previous analyses have suggested that interventional therapies would reduce cardiovascular events in CAD patients with documented ischemia, recent post-hoc studies and metanalysis have shown distinct results. In this review article, the authors discuss myocardial ischemia, the different responses of the myocardium to ischemic insults, ischemic preconditioning, and the main findings of recent studies about the clinical aspects and treatment of patients with chronic, documented myocardial ischemia.
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Affiliation(s)
- Paulo Cury Rezende
- Instituto do Coracao (InCor), Hospital das Clinicas HCFMUSP, Faculdade de Medicina, Universidade de São Paulo, São Paulo, Brazil
| | - Fernando Faglioni Ribas
- Instituto do Coracao (InCor), Hospital das Clinicas HCFMUSP, Faculdade de Medicina, Universidade de São Paulo, São Paulo, Brazil
| | - Carlos Vicente Serrano
- Instituto do Coracao (InCor), Hospital das Clinicas HCFMUSP, Faculdade de Medicina, Universidade de São Paulo, São Paulo, Brazil
| | - Whady Hueb
- Instituto do Coracao (InCor), Hospital das Clinicas HCFMUSP, Faculdade de Medicina, Universidade de São Paulo, São Paulo, Brazil
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Rovira M, Borràs DM, Marques IJ, Puig C, Planas JV. Physiological Responses to Swimming-Induced Exercise in the Adult Zebrafish Regenerating Heart. Front Physiol 2018; 9:1362. [PMID: 30327615 PMCID: PMC6174316 DOI: 10.3389/fphys.2018.01362] [Citation(s) in RCA: 26] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/17/2018] [Accepted: 09/07/2018] [Indexed: 01/07/2023] Open
Abstract
Exercise promotes a set of physiological responses known to provide long-term health benefits and it can play an important role in cardioprotection. In the present study, we examined cardiac responses to exercise training in the adult zebrafish and in the context of cardiac regeneration. We found that swimming-induced exercise increased cardiomyocyte proliferation and that this response was also found under regenerating conditions, when exercise was performed either prior to and after ventricular cryoinjury (CI). Exercise prior to CI resulted in a mild improvement in cardiac function and lesion recovery over the non-exercise condition. Transcriptomic profiling of regenerating ventricles in cryoinjured fish subjected to exercise identified genes possibly involved in the cardioprotective effects of exercise and that could represent potential targets for heart regeneration strategies. Taken together, our results suggest that exercise constitutes a physiological stimulus that may help promote cardiomyogenic mechanisms of the vertebrate heart through the induction of cardiomyocyte proliferation. The zebrafish exercise model may be useful for investigating the potential cardioprotective effects of exercise in teleost fish and to contribute to further identify and develop novel avenues in basic research to promote heart regeneration.
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Affiliation(s)
- Mireia Rovira
- Departament de Biologia Cellular, Fisiologia i Immunologia, Facultat de Biologia, Universitat de Barcelona, Barcelona, Spain
| | - Daniel M Borràs
- Research and Development Department, GenomeScan B.V., Leiden, Netherlands
| | - Inês J Marques
- Institute of Anatomy, University of Bern, Bern, Switzerland
| | - Carolina Puig
- Departament de Biologia Cellular, Fisiologia i Immunologia, Facultat de Biologia, Universitat de Barcelona, Barcelona, Spain
| | - Josep V Planas
- Departament de Biologia Cellular, Fisiologia i Immunologia, Facultat de Biologia, Universitat de Barcelona, Barcelona, Spain
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Stokfisz K, Ledakowicz-Polak A, Zagorski M, Zielinska M. Ischaemic preconditioning - Current knowledge and potential future applications after 30 years of experience. Adv Med Sci 2017; 62:307-316. [PMID: 28511069 DOI: 10.1016/j.advms.2016.11.006] [Citation(s) in RCA: 54] [Impact Index Per Article: 7.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/12/2016] [Revised: 10/19/2016] [Accepted: 11/29/2016] [Indexed: 12/16/2022]
Abstract
Ischaemic preconditioning (IPC) phenomenon has been known for thirty years. During that time several studies showed that IPC provided by brief ischaemic and reperfusion episodes prior to longer ischaemia can bestow a protective effect to both preconditioned and also remote organs. IPC affecting remote organs is called remote ischaemic preconditioning. Initially, most IPC studies were focused on enhancing myocardial resistance to subsequent ischaemia and reperfusion injury. However, preconditioning was found to be a universal phenomenon and was observed in various organs and tissues including the heart, liver, brain, retina, kidney, skeletal muscles and intestine. Currently, there are a lot of simultaneous studies are underway aiming at finding out whether IPC can be helpful in protecting these organs. The mechanism of local and remote IPC is complex and not well known. Several triggers, intracellular pathways and effectors, humoral, neural and induced by genetic changes may be considered potential pathways in the protective activity of local and remote IPC. Local and remote IPC mechanism may potentially serve as heart protection during cardiac surgery and may limit the infarct size of the myocardium, can be a strategy for preventing the development of acute kidney injury development and liver damage during transplantation, may protect the brain against ischaemic injury. In addition, the method is safe, non-invasive, cheap and easily applicable. The main purpose of this review article is to present new advances which would help to understand the potential mechanism of IPC. It also discusses both its potential applications and utility in clinical settings.
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Affiliation(s)
- Karolina Stokfisz
- Intensive Cardiac Therapy Clinic, Department of Invasive Cardiology and Electrocardiology, Medical University, Lodz, Poland.
| | - Anna Ledakowicz-Polak
- Intensive Cardiac Therapy Clinic, Department of Invasive Cardiology and Electrocardiology, Medical University, Lodz, Poland
| | - Maciej Zagorski
- Cardiosurgery Clinic, Department of Cardiology and Cardiosurgery, Medical University, Lodz, Poland
| | - Marzenna Zielinska
- Intensive Cardiac Therapy Clinic, Department of Invasive Cardiology and Electrocardiology, Medical University, Lodz, Poland
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6
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Chen HSV, Body SC, Shernan SK. Myocardial Preconditioning: Characteristics, Mechanisms, and Clinical Applications. Semin Cardiothorac Vasc Anesth 2016. [DOI: 10.1177/108925329900300205] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
Perioperative myocardial ischemia and dysfunction re main prevalent after cardiac surgery despite the use of conventional measures to provide myocardial protec tion. Myocardial preconditioning is a powerful, endog enously regulated means of myocardial protection that may also have some clinical usage for patients undergo ing cardiac surgical procedures. The paradoxical con cept of using ischemia as a stimulus for myocardial protection has been studied extensively in animals and humans. The specific characteristics and constituents of preconditioning have been well identified. The mecha nism remains to be completely elucidated due to differ ences among species and experimental models. Some pharmacologic agents are capable of mimicking the classic mechanism of ischemic preconditioning. Pharma cologic and ischemic preconditioning may have signifi cant clinical use and therapeutic efficacy as a means of providing myocardial protection during cardiac surgery, especially in procedures that do not use cardioplegia and cardiopulmonary bypass, such as minimally inva sive coronary artery bypass grafting. This article re views the characteristics, mechanisms, potential clini cal applications, and therapeutic efficacy of myocardial preconditioning.
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Affiliation(s)
- Huei-Sheng Vincent Chen
- Departments of Medicine and Anesthesiology, Perioperative and Pain Medicine at Brigham and Women's Hospital, Harvard Medical School, Boston, MA
| | - Simon C. Body
- Departments of Medicine and Anesthesiology, Perioperative and Pain Medicine at Brigham and Women's Hospital, Harvard Medical School, Boston, MA
| | - Stanton K. Shernan
- Departments of Medicine and Anesthesiology, Perioperative and Pain Medicine at Brigham and Women's Hospital, Harvard Medical School, Boston, MA
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7
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Rezende PC, Rahmi RM, Hueb W. The Influence of Diabetes Mellitus in Myocardial Ischemic Preconditioning. J Diabetes Res 2016; 2016:8963403. [PMID: 27656659 PMCID: PMC5021496 DOI: 10.1155/2016/8963403] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/18/2016] [Accepted: 08/14/2016] [Indexed: 11/24/2022] Open
Abstract
Ischemic preconditioning (IP) is a powerful mechanism of protection discovered in the heart in which ischemia paradoxically protects the myocardium against other ischemic insults. Many factors such as diseases and medications may influence IP expression. Although diabetes poses higher cardiovascular risk, the physiopathology underlying this condition is uncertain. Moreover, although diabetes is believed to alter intracellular pathways related to myocardial protective mechanisms, it is still controversial whether diabetes may interfere with ischemic preconditioning and whether this might influence clinical outcomes. This review article looks at published reports with animal models and humans that tried to evaluate the possible influence of diabetes in myocardial ischemic preconditioning.
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Affiliation(s)
- Paulo Cury Rezende
- Department of Atherosclerosis, Heart Institute of the University of São Paulo Medical School, São Paulo, SP, Brazil
| | - Rosa Maria Rahmi
- Department of Atherosclerosis, Heart Institute of the University of São Paulo Medical School, São Paulo, SP, Brazil
| | - Whady Hueb
- Department of Atherosclerosis, Heart Institute of the University of São Paulo Medical School, São Paulo, SP, Brazil
- *Whady Hueb:
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Exercise-induced ischemic preconditioning and the potential application to cardiac rehabilitation: a systematic review. J Cardiopulm Rehabil Prev 2015; 35:93-102. [PMID: 25622217 DOI: 10.1097/hcr.0000000000000099] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/22/2023]
Abstract
Exercise-induced ischemic preconditioning (IPC) can be assessed by the results of the second of sequential exercise tests. Exercise-induced IPC is quantified by using the time to 1-mm ST-segment depression, the rate-pressure product at 1-mm ST-segment depression, the maximal ST-segment depression, and the rate-pressure product at the peak of exercise. Few studies reported whether exercise-induced IPC could be used in cardiovascular rehabilitation. A systematic review of the literature limited to human studies was performed using electronic databases, and the main key words were ischemic preconditioning, warm-up phenomenon, and exercise. After careful review, 38 articles were included in the systematic review. This review summarizes the molecular pathways of IPC and describes the first window of protection induced by sequential exercise tests, as well as the effect of medication on exercise-induced IPC. A section on the exercise protocol, mode of exercise, and intensity provides understanding as to what is needed for clinicians to induce IPC with sequential stress tests. The final section of the review is a discussion of the potential use of exercise-induced IPC in a cardiovascular rehabilitation setting. Even if exercise-induced IPC is a well-documented phenomenon, additional studies are needed in order to more fully understand its use in rehabilitation.
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Wojciechowska M, Zarębiński M, Pawluczuk P, Szukiewicz D. Decreased effectiveness of ischemic heart preconditioning in the state of chronic inflammation. Med Hypotheses 2015; 85:675-9. [PMID: 26342834 DOI: 10.1016/j.mehy.2015.08.008] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/14/2014] [Revised: 06/25/2015] [Accepted: 08/13/2015] [Indexed: 10/23/2022]
Abstract
There is growing evidence, that beneficial effects of ischemic heart preconditioning (IPC) may be lost or limited due to diabetes, hyperlipidemia, hypertension, atherosclerosis, heart failure and senility. It is plausible, that these conditions interfere with the biochemical pathways underlying the IPC response, but the detailed explanation is not clear. Pro-inflammatory cytokines (IL-1β, IL-6, TNF-α), monocyte chemotactic protein-1 (MCP-1), histamine and many other agents used in a single dose before prolonged ischemia mimic IPC. However prolonged exposure to preconditioning mimetics leads to tolerance (tachyphylaxis). In the state of such tolerance ischemic preconditioning is no longer protective. Studies suggest that diabetes, hyperlipidemia, hypertension, atherosclerosis, heart failure and older age are accompanied by increased plasma levels of pro-inflammatory cytokines, MCP-1 and other inflammatory mediators. Therefore, we raised the hypothesis, that the reported lack of benefits of IPC in the listed states may be due to tolerance to IPC developed during prolonged exposure of the myocardium to preconditioning mimetics.
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Affiliation(s)
- M Wojciechowska
- Department of General and Experimental Pathology, Medical University of Warsaw, Pawińskiego 3 C, 02-106 Warsaw, Poland; Invasive Cardiology Unit, Western Hospital, Daleka 11, 05-825 Grodzisk Mazowiecki, Poland.
| | - M Zarębiński
- Invasive Cardiology Unit, Western Hospital, Daleka 11, 05-825 Grodzisk Mazowiecki, Poland
| | - P Pawluczuk
- Invasive Cardiology Unit, Western Hospital, Daleka 11, 05-825 Grodzisk Mazowiecki, Poland
| | - D Szukiewicz
- Department of General and Experimental Pathology, Medical University of Warsaw, Pawińskiego 3 C, 02-106 Warsaw, Poland
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Costa LMA, Rezende PC, Garcia RMR, Uchida AH, Seguro LFBC, Scudeler TL, Bocchi EA, Krieger JE, Hueb W, Ramires JAF, Filho RK. Role of Trimetazidine in Ischemic Preconditioning in Patients With Symptomatic Coronary Artery Disease. Medicine (Baltimore) 2015; 94:e1161. [PMID: 26287407 PMCID: PMC4616436 DOI: 10.1097/md.0000000000001161] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/30/2022] Open
Abstract
Ischemic preconditioning (IP) is a powerful cardioprotective cellular mechanism that has been related to the "warm-up phenomenon" or "walk-through" angina, and has been documented through the use of sequential exercise tests (ETs). It is known that several drugs, for example, cromokalim, pinacidil, adenosine, and nicorandil, can interfere with the cellular pathways of IP. The purpose of this article is to report the effect of the anti-ischemic agent trimetazidine (TMZ) on IP in symptomatic coronary artery disease (CAD) patients.We conducted a prospective study evaluating IP by the analysis of ischemic parameters in 2 sequential ETs. In phase I, without TMZ, patients underwent ET1 and ET2 with a 30-minute interval between them. In phase II, after 1 week of TMZ 35 mg twice daily, all patients underwent 2 consecutive ETs (ET3 and ET4). IP was considered present when the time to 1.0-mm segment ST on electrocardiogram deviation (T-1.0 mm) and rate pressure product (RPP) were greater in the second of 2 tests. The improvement in T-1.0 mm and RPP were compared in the 2 phases: without TMZ and after 1-week TMZ to assess the action of such drug in myocardial protective mechanisms. ETs were analyzed by 2 independent cardiologists.From 135 CAD patients screened, 96 met inclusion criteria and 62 completed the study protocol. Forty patients manifested IP by demonstrating an improvement in T-1.0 mm in ET2 compared with ET1, without the use of any drugs (phase I). In phase II, after 1-week TMZ, 26 patients (65%) did not show any incremental result in ischemic parameters in ET4 compared with ET3. Furthermore, of these patients, 8 (20%) had IP blockage.In this study, TMZ did not add any benefit to IP in patients with stable symptomatic CAD.
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Affiliation(s)
- Leandro M A Costa
- From the Department of Atherosclerosis, Heart Institute (InCor) of the University of São Paulo, São Paulo, Brazil
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Rezende PC, Rahmi RM, Uchida AH, da Costa LMA, Scudeler TL, Garzillo CL, Lima EG, Segre CAW, Girardi P, Takiuti M, Silva MF, Hueb W, Ramires JAF, Kalil Filho R. Type 2 diabetes mellitus and myocardial ischemic preconditioning in symptomatic coronary artery disease patients. Cardiovasc Diabetol 2015; 14:66. [PMID: 26025451 PMCID: PMC4451743 DOI: 10.1186/s12933-015-0228-x] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/06/2015] [Accepted: 05/21/2015] [Indexed: 01/10/2023] Open
Abstract
Background The influence of diabetes mellitus on myocardial ischemic preconditioning is not clearly defined. Experimental studies are conflicting and human studies are scarce and inconclusive. Objectives Identify whether diabetes mellitus intervenes on ischemic preconditioning in symptomatic coronary artery disease patients. Methods Symptomatic multivessel coronary artery disease patients with preserved systolic ventricular function and a positive exercise test underwent two sequential exercise tests to demonstrate ischemic preconditioning. Ischemic parameters were compared among patients with and without type 2 diabetes mellitus. Ischemic preconditioning was considered present when the time to 1.0 mm ST deviation and rate pressure-product were greater in the second of 2 exercise tests. Sequential exercise tests were analyzed by 2 independent cardiologists. Results Of the 2,140 consecutive coronary artery disease patients screened, 361 met inclusion criteria, and 174 patients (64.2 ± 7.6 years) completed the study protocol. Of these, 86 had the diagnosis of type 2 diabetes. Among diabetic patients, 62 (72 %) manifested an improvement in ischemic parameters consistent with ischemic preconditioning, whereas among nondiabetic patients, 60 (68 %) manifested ischemic preconditioning (p = 0.62). The analysis of patients who demonstrated ischemic preconditioning showed similar improvement in the time to 1.0 mm ST deviation between diabetic and nondiabetic groups (79.4 ± 47.6 vs 65.5 ± 36.4 s, respectively, p = 0.12). Regarding rate pressure-product, the improvement was greater in diabetic compared to nondiabetic patients (3011 ± 2430 vs 2081 ± 2139 bpm x mmHg, respectively, p = 0.01). Conclusions In this study, diabetes mellitus was not associated with impairment in ischemic preconditioning in symptomatic coronary artery disease patients. Furthermore, diabetic patients experienced an improvement in this significant mechanism of myocardial protection.
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Affiliation(s)
- Paulo Cury Rezende
- Department of Atherosclerosis, Heart Institute (InCor) of the University of São Paulo, Av. Dr. Eneas de Carvalho Aguiar 44, AB, Sala 114, 05403-000, Cerqueira César, São Paulo, Brazil.
| | - Rosa Maria Rahmi
- Department of Atherosclerosis, Heart Institute (InCor) of the University of São Paulo, Av. Dr. Eneas de Carvalho Aguiar 44, AB, Sala 114, 05403-000, Cerqueira César, São Paulo, Brazil.
| | - Augusto Hiroshi Uchida
- Department of Atherosclerosis, Heart Institute (InCor) of the University of São Paulo, Av. Dr. Eneas de Carvalho Aguiar 44, AB, Sala 114, 05403-000, Cerqueira César, São Paulo, Brazil.
| | - Leandro Menezes Alves da Costa
- Department of Atherosclerosis, Heart Institute (InCor) of the University of São Paulo, Av. Dr. Eneas de Carvalho Aguiar 44, AB, Sala 114, 05403-000, Cerqueira César, São Paulo, Brazil.
| | - Thiago Luis Scudeler
- Department of Atherosclerosis, Heart Institute (InCor) of the University of São Paulo, Av. Dr. Eneas de Carvalho Aguiar 44, AB, Sala 114, 05403-000, Cerqueira César, São Paulo, Brazil.
| | - Cibele Larrosa Garzillo
- Department of Atherosclerosis, Heart Institute (InCor) of the University of São Paulo, Av. Dr. Eneas de Carvalho Aguiar 44, AB, Sala 114, 05403-000, Cerqueira César, São Paulo, Brazil.
| | - Eduardo Gomes Lima
- Department of Atherosclerosis, Heart Institute (InCor) of the University of São Paulo, Av. Dr. Eneas de Carvalho Aguiar 44, AB, Sala 114, 05403-000, Cerqueira César, São Paulo, Brazil.
| | - Carlos Alexandre Wainrober Segre
- Department of Atherosclerosis, Heart Institute (InCor) of the University of São Paulo, Av. Dr. Eneas de Carvalho Aguiar 44, AB, Sala 114, 05403-000, Cerqueira César, São Paulo, Brazil.
| | - Priscyla Girardi
- Department of Atherosclerosis, Heart Institute (InCor) of the University of São Paulo, Av. Dr. Eneas de Carvalho Aguiar 44, AB, Sala 114, 05403-000, Cerqueira César, São Paulo, Brazil.
| | - Myrthes Takiuti
- Department of Atherosclerosis, Heart Institute (InCor) of the University of São Paulo, Av. Dr. Eneas de Carvalho Aguiar 44, AB, Sala 114, 05403-000, Cerqueira César, São Paulo, Brazil.
| | - Marcela Francisca Silva
- Department of Atherosclerosis, Heart Institute (InCor) of the University of São Paulo, Av. Dr. Eneas de Carvalho Aguiar 44, AB, Sala 114, 05403-000, Cerqueira César, São Paulo, Brazil.
| | - Whady Hueb
- Department of Atherosclerosis, Heart Institute (InCor) of the University of São Paulo, Av. Dr. Eneas de Carvalho Aguiar 44, AB, Sala 114, 05403-000, Cerqueira César, São Paulo, Brazil.
| | - Jose Antonio Franchini Ramires
- Department of Atherosclerosis, Heart Institute (InCor) of the University of São Paulo, Av. Dr. Eneas de Carvalho Aguiar 44, AB, Sala 114, 05403-000, Cerqueira César, São Paulo, Brazil.
| | - Roberto Kalil Filho
- Department of Atherosclerosis, Heart Institute (InCor) of the University of São Paulo, Av. Dr. Eneas de Carvalho Aguiar 44, AB, Sala 114, 05403-000, Cerqueira César, São Paulo, Brazil.
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Marongiu E, Crisafulli A. Cardioprotection acquired through exercise: the role of ischemic preconditioning. Curr Cardiol Rev 2014; 10:336-48. [PMID: 24720421 PMCID: PMC4101198 DOI: 10.2174/1573403x10666140404110229] [Citation(s) in RCA: 62] [Impact Index Per Article: 6.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/14/2013] [Revised: 12/16/2013] [Accepted: 03/28/2014] [Indexed: 02/07/2023] Open
Abstract
A great bulk of evidence supports the concept that regular exercise training can reduce the incidence of coronary events and increase survival chances after myocardial infarction. These exercise-induced beneficial effects on the myocardium are reached by means of the reduction of several risk factors relating to cardiovascular disease, such as high cholesterol, hypertension, obesity etc. Furthermore, it has been demonstrated that exercise can reproduce the "ischemic preconditioning" (IP), which refers to the capacity of short periods of ischemia to render the myocardium more resistant to subsequent ischemic insult and to limit infarct size during prolonged ischemia. However, IP is a complex phenomenon which, along with infarct size reduction, can also provide protection against arrhythmia and myocardial stunning due to ischemia-reperfusion. Several clues demonstrate that preconditioning may be directly induced by exercise, thus inducing a protective phenotype at the heart level without the necessity of causing ischemia. Exercise appears to act as a physiological stress that induces beneficial myocardial adaptive responses at cellular level. The purpose of the present paper is to review the latest data on the role played by exercise in triggering myocardial preconditioning.
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13
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Rezende PC, Garcia RMR, Uchida AH, Costa LMA, Scudeler TL, Melo RMV, Oikawa FTC, Garzillo CL, Lima EG, Segre CAW, Favarato D, Girardi P, Takiuti M, Strunz CC, Hueb W, Ramires JAF, Filho RK. Hypotheses, rationale, design, and methods for evaluation of ischemic preconditioning assessed by sequential exercise tests in diabetic and non-diabetic patients with stable coronary artery disease--a prospective study. BMC Cardiovasc Disord 2013; 13:117. [PMID: 24330253 PMCID: PMC4029531 DOI: 10.1186/1471-2261-13-117] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/17/2013] [Accepted: 12/03/2013] [Indexed: 01/18/2023] Open
Abstract
BACKGROUND Ischemic preconditioning is a powerful mechanism of myocardial protection and in humans it can be evaluated by sequential exercise tests. Coronary Artery Disease in the presence of diabetes mellitus may be associated with worse outcomes. In addition, some studies have shown that diabetes interferes negatively with the development of ischemic preconditioning. However, it is still unknown whether diabetes may influence the expression of ischemic preconditioning in patients with stable multivessel coronary artery disease. METHODS/DESIGN This study will include 140 diabetic and non-diabetic patients with chronic, stable coronary artery disease and preserved left ventricular systolic function. The patients will be submitted to two sequential exercise tests with 30-minutes interval between them. Ischemic parameters will be compared between diabetic and non-diabetic patients. Ischemic preconditioning will be considered present when time to 1.0 mm ST-segment deviation is greater in the second of two sequential exercise tests. Exercise tests will be analyzed by two independent cardiologists. DISCUSSION Ischemic preconditioning was first demonstrated by Murry et al. in dog's hearts. Its work was reproduced by other authors, clearly demonstrating that brief periods of myocardial ischemia followed by reperfusion triggers cardioprotective mechanisms against subsequent and severe ischemia. On the other hand, the demonstration of ischemic preconditioning in humans requires the presence of clinical symptoms or physiological changes difficult to be measured. One methodology largely accepted are the sequential exercise tests, in which, the improvement in the time to 1.0 mm ST depression in the second of two sequential tests is considered manifestation of ischemic preconditioning.Diabetes is an important and independent determinant of clinical prognosis. It's a major risk factor for coronary artery disease. Furthermore, the association of diabetes with stable coronary artery disease imposes worse prognosis, irrespective of treatment strategy. It's still not clearly known the mechanisms responsible by these worse outcomes. Impairment in the mechanisms of ischemic preconditioning may be one major cause of this worse prognosis, but, in the clinical setting, this is not known. The present study aims to evaluate how diabetes mellitus interferes with ischemic preconditioning in patients with stable, multivessel coronary artery disease and preserved systolic ventricular function.
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Affiliation(s)
- Paulo Cury Rezende
- Department of Atherosclerosis, Heart Institute of the University of Sao Paulo, Sao Paulo, Brazil
| | - Rosa Maria Rahmi Garcia
- Department of Atherosclerosis, Heart Institute of the University of Sao Paulo, Sao Paulo, Brazil
| | - Augusto Hiroshi Uchida
- Department of Atherosclerosis, Heart Institute of the University of Sao Paulo, Sao Paulo, Brazil
| | | | - Thiago Luis Scudeler
- Department of Atherosclerosis, Heart Institute of the University of Sao Paulo, Sao Paulo, Brazil
| | | | | | - Cibele Larrosa Garzillo
- Department of Atherosclerosis, Heart Institute of the University of Sao Paulo, Sao Paulo, Brazil
| | - Eduardo Gomes Lima
- Department of Atherosclerosis, Heart Institute of the University of Sao Paulo, Sao Paulo, Brazil
| | | | - Desiderio Favarato
- Department of Atherosclerosis, Heart Institute of the University of Sao Paulo, Sao Paulo, Brazil
| | - Priscyla Girardi
- Department of Atherosclerosis, Heart Institute of the University of Sao Paulo, Sao Paulo, Brazil
| | - Myrthes Takiuti
- Department of Atherosclerosis, Heart Institute of the University of Sao Paulo, Sao Paulo, Brazil
| | - Celia Cassaro Strunz
- Department of Atherosclerosis, Heart Institute of the University of Sao Paulo, Sao Paulo, Brazil
| | - Whady Hueb
- Department of Atherosclerosis, Heart Institute of the University of Sao Paulo, Sao Paulo, Brazil
| | | | - Roberto Kalil Filho
- Department of Atherosclerosis, Heart Institute of the University of Sao Paulo, Sao Paulo, Brazil
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14
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Lalonde F, Poirier P, Sylvestre MP, Arvisais D, Curnier D. Exercise-induced ischemic preconditioning detected by sequential exercise stress tests: A meta-analysis. Eur J Prev Cardiol 2013; 22:100-12. [DOI: 10.1177/2047487313502447] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/21/2023]
Affiliation(s)
- François Lalonde
- Laboratoire de Physiopathologie de l'Exercice, Département de Kinésiologie, Université de Montréal, Canada
- Centre de Recherche du Centre Hospitalier Universitaire de Montréal, Canada
| | - Paul Poirier
- Faculté de Pharmacie, Université Laval, Canada; Institut universitaire de cardiologie et de pneumologie de Québec, Université Laval, Canada
| | - Marie-Pierre Sylvestre
- Centre de Recherche du Centre Hospitalier Universitaire de Montréal, Canada
- Département de Médecine Préventive et Sociale, Université de Montréal, Canada
| | - Denis Arvisais
- Direction des bibliothéques, Universitéde Montréal, Canada
| | - Daniel Curnier
- Laboratoire de Physiopathologie de l'Exercice, Département de Kinésiologie, Université de Montréal, Canada
- Centre de Recherche du Centre Hospitalier Universitaire de Montréal, Canada
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15
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Li J, Luan X, Clark JC, Rafols JA, Ding Y. Neuroprotection against transient cerebral ischemia by exercise pre-conditioning in rats. Neurol Res 2013; 26:404-8. [PMID: 15198867 DOI: 10.1179/016164104225016038] [Citation(s) in RCA: 44] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/31/2022]
Abstract
There is increasing evidence that physical activity is associated with decreased stroke risk and incidence. The purpose of this study was to determine whether increased levels of physical activity could reduce brain damage in rats subjected to transient or permanent middle cerebral artery (MCA) occlusion. Adult male Sprague-Dawley rats (three months old, n=36) exercised on a treadmill, which required repetitive locomotor movement, for 30 min each day for three weeks. Then, using an intraluminal filament, stroke was induced by either 2-h MCA occlusion followed by two days of reperfusion or by MCA occlusion for two days without reperfusion. Brain damage was determined by evaluating neurologic deficits and brain infarction. In rat with transient MCA occlusion, pre-ischemic motor activity significantly (p<0.01) reduced neurologic deficits and infarct volume in the frontoparietal cortex and the dorsolateral striatum. In contrast, the same exercise procedure did not produce neuroprotection in the permanently MCA-occluded stroke. In addition to decreasing stroke risk and incidence, physical activity also reduces brain damage after stroke. Although we cannot completely rule out a neuroprotective effect on ischemic episode, our study suggests that a major neuroprotection is conferred during reperfusion for rats that have undergone exercise pre-conditioning. This exercise-induced endogenous neuroprotection may be an effective strategy to ameliorate ischemia/reperfusion brain injury from stroke.
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Affiliation(s)
- Jie Li
- Department of Neurological Surgery, Wayne State University School of Medicine, Detroit, MI 48201, USA
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16
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Williams RP, Manou-Stathopoulou V, Redwood SR, Marber MS. ‘Warm-up Angina’: harnessing the benefits of exercise and myocardial ischaemia. Heart 2013; 100:106-14. [DOI: 10.1136/heartjnl-2013-304187] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/09/2023] Open
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17
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Rahmi RM, Uchida AH, Rezende PC, Lima EG, Garzillo CL, Favarato D, Strunz CMC, Takiuti M, Girardi P, Hueb W, Kalil Filho R, Ramires JAF. Effect of hypoglycemic agents on ischemic preconditioning in patients with type 2 diabetes and symptomatic coronary artery disease. Diabetes Care 2013; 36:1654-9. [PMID: 23250803 PMCID: PMC3661846 DOI: 10.2337/dc12-1495] [Citation(s) in RCA: 25] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/03/2023]
Abstract
OBJECTIVE To assess the effect of two hypoglycemic drugs on ischemic preconditioning (IPC) patients with type 2 diabetes and coronary artery disease (CAD). RESEARCH DESIGN AND METHODS We performed a prospective study of 96 consecutive patients allocated into two groups: 42 to group repaglinide (R) and 54 to group vildagliptin (V). All patients underwent two consecutive exercise tests (ET1 and ET2) in phase 1 without drugs. In phase 2, 1 day after ET1 and -2, 2 mg repaglinide three times daily or 50 mg vildagliptin twice daily was given orally to patients in the respective group for 6 days. On the seventh day, 60 min after 6 mg repaglinide or 100 mg vildagliptin, all patients underwent two consecutive exercise tests (ET3 and ET4). RESULTS In phase 1, IPC was demonstrated by improvement in the time to 1.0 mm ST-segment depression and rate pressure product (RPP). All patients developed ischemia in ET3; however, 83.3% of patients in group R experienced ischemia earlier in ET4, without significant improvement in RPP, indicating the cessation of IPC (P < 0.0001). In group V, only 28% of patients demonstrated IPC cessation, with 72% still having the protective effect (P < 0.0069). CONCLUSIONS Repaglinide eliminated myocardial IPC, probably by its effect on the KATP channel. Vildagliptin did not damage this protective mechanism in a relevant way in patients with type 2 diabetes and CAD, suggesting a good alternative treatment in this population.
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Affiliation(s)
- Rosa Maria Rahmi
- Department of Atherosclerosis, Heart Institute of the University of São Paulo, São Paulo, Brazil
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18
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Michaelides AP, Fourlas CA, Andrikopoulos GK, Antoniades C, Soulis D, Chatzistamatiou E, Stefanadis CI. Correlation of modification of heart rate recovery with adaptation to myocardial ischemia in a model of sequential exercise testings. Ann Noninvasive Electrocardiol 2008; 13:364-70. [PMID: 18973493 DOI: 10.1111/j.1542-474x.2008.00247.x] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/30/2022] Open
Abstract
BACKGROUND Heart rate recovery (HRR) has been identified as a reliable predictor of cardiac mortality, correlated with autonomic tone. In a model of sequential exercise testings, we investigated the reproducibility of HRR and the association between HRR modification and myocardial adaptation to ischemia. METHODS We studied 128 patients (mean age 62 +/- 9 years, 83% males) with angiographically documented coronary artery disease (CAD) and a first positive exercise testing, who agreed to undergo a second exercise testing after 24 hours. RESULTS HRR was increased from 25 +/- 10 beats/min at the first exercise testing to 30 +/- 13 beats/min at the second exercise testing (P < 0.001). Thereafter, participants were divided into two groups: Group I comprised 88 patients who presented augmentation of the HRR in the first compared to the second exercise testing, while group II comprised 40 patients who presented unchanged or reduced HRR. The rate-pressure product (RPP) at 1 mm ST-segment depression (ischemic threshold) at the second compared to the first exercise testing were significantly improved in group I patients (2345 +/- 3429 mmHg/min), while it was worsened in group II patients (-630 +/- 2510 mmHg/min) (P < 0.001). CONCLUSIONS In a model of sequential exercise testings, myocardial adaptation to exercise-induced ischemia was associated with favorable modification of HRR.
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Affiliation(s)
- Andreas P Michaelides
- First Department of Cardiology, Medical School of Athens University, Hippokration Hospital, Athens, Greece.
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19
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Marinaccio L, Lanza GA, Niccoli G, Fabretti A, Lamendola P, Barone L, Di Monaco A, Di Clemente F, Crea F. Effect of low doses of alcohol on the warm-up phenomenon in patients with stable angina pectoris. Am J Cardiol 2008; 102:146-9. [PMID: 18602511 DOI: 10.1016/j.amjcard.2008.03.025] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/01/2008] [Revised: 03/07/2008] [Accepted: 03/07/2008] [Indexed: 11/15/2022]
Abstract
Experimental studies suggest that alcohol may have protective effects similar to that of ischemic preconditioning (IPC). The acute effects of alcohol on IPC in humans, however, are poorly known. In this study, we assessed the effect of alcohol administration on the warm-up phenomenon, as an expression of IPC, in patients with stable coronary artery disease (CAD). We randomized 45 stable CAD patients with positive (ST-segment depression > or =1 mm) exercise stress test to 1 of 3 groups of 15 patients each: (1) group 1 = 60 cc of gin (18.5 g of ethanol); (2) group 2 = 180 cc of red wine (18.9 g of ethanol); and (3) group 3 = placebo (120 cc of water). A first exercise test was performed 15 minutes after beverage administration. In those with a positive exercise test (13, 14, and 14 patients in the gin, wine, and placebo groups, respectively), a second exercise test was performed 15 minutes after the end of the first one. On the first test, there were no differences among groups in rate pressure product and time of exercise at 1-mm ST-segment depression, as well as in maximal ST segment depression. Furthermore, an improvement of the ischemic exercise variables was observed in each group, without any statistically significant differences among them. In conclusion, our data show that, in stable CAD patients, the acute intake of low doses of alcohol does not significantly influence IPC, as expressed by the warm-up phenomenon on exercise stress testing.
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Vinokur V, Leibowitz G, Grinberg L, Eliashar R, Berenshtein E, Chevion M. Diabetes and the heart: could the diabetic myocardium be protected by preconditioning? Redox Rep 2008; 12:246-56. [PMID: 17961296 DOI: 10.1179/135100007x239289] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/24/2023] Open
Abstract
Both type 1 and type 2 diabetes (insulin-dependent and non-insulin dependent diabetes, respectively) are associated with increased risk for microvascular and macrovascular complications including retinopathy, neuropathy, nephropathy and atherosclerosis. Type 2 diabetes markedly increases the risk for cardiovascular morbidity and mortality, which has major public health implications. In this review, molecular mechanisms pertaining to diabetes-induced heart pathology are addressed.
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Affiliation(s)
- Vladimir Vinokur
- Department of Cellular Biochemistry and Human Genetics, The Hebrew University of Jerusalem, Jerusalem, Israel
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21
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Abstract
The purpose of this review is to describe in more detail ischemia reperfusion injury and preconditioning, and to speculate on the potential role of preconditioning in the care of critically ill patients. Current hemodynamic treatment of hypotension and hypoperfusion in critically ill patients is directed at ensuring essential organ perfusion by maintaining intravascular volume and cardiac output, and ensuring adequate oxygen delivery by maintaining arterial oxygen partial pressure and hemoglobin levels. However, morbidity and mortality remain high and new approaches to critically ill patients are required. Treatments are needed that can protect against organ ischemia during periods of low blood flow. In recent years, there has been a growing appreciation of the importance of ischemia reperfusion injury. Ischemia associated with reperfusion may result in greater injury than ischemia alone. Ischemic preconditioning is used to describe the protective effect of short periods of ischemia to an organ or tissue against longer periods of ischemia. Although first described in the myocardium, there is now evidence that this phenomenon occurs in a wide variety of organs and tissues, including the brain and other nervous tissue such as the retina and spinal cord, liver, stomach, intestines, kidney, and the lungs. Preconditioning therapy may offer a new avenue of treatment in critically ill patients. Both traditional preconditioning methods and pharmacologic agents that mimic or induce such preconditioning may be used in the future. Clinical trials of pharmacologic agents are underway in patients with coronary artery disease. Further trials of such methods and agents are needed in critically ill patients suffering from sepsis or multiorgan system failure.
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Affiliation(s)
- Peter Rock
- Department of Anesthesiology, University of North Carolina, Chapel Hill, North Carolina 27599, USA.
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22
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Kloner RA, Shook T, Cannon CP, Przyklenk K. Ischemic Preconditioning: Implications for the Geriatric Heart. ACTA ACUST UNITED AC 2007; 10:145-8; quiz 149-51. [PMID: 11360839 DOI: 10.1111/j.1076-7460.2001.00002.x] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
Abstract
Ischemic preconditioning is among the most consistent and powerful modes of reducing myocardial infarct size. Although several clinical studies have suggested that the human heart can be preconditioned, controversy exists in both the experimental and clinical literature as to whether the senescent heart can be preconditioned. The authors recently reported that older patients (> or = 60 years of age) in the Thrombolysis in Myocardial Infarction-4 study appeared to benefit from a history of angina prior to acute myocardial infarction. This observation may lead to a clinical counterpart to successful preconditioning in the older heart.
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Affiliation(s)
- R A Kloner
- Heart Institute, Good Samaritan Hospital, 1225 Wilshire Boulevard, Los Angeles, CA 90017, USA
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23
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Hueb W, Uchida AH, Gersh BJ, Betti RTB, Lopes N, Moffa PJ, Ferreira BMA, Ramires JAF, Wajchenberg BL. Effect of a hypoglycemic agent on ischemic preconditioning in patients with type 2 diabetes and stable angina pectoris. Coron Artery Dis 2007; 18:55-9. [PMID: 17172931 DOI: 10.1097/mca.0b013e328011c0a9] [Citation(s) in RCA: 20] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/15/2022]
Abstract
OBJECTIVE Ischemic preconditioning is an increased tolerance to myocardial ischemia during the second of two consecutive exercise tests. ATP-sensitive K(+) channel blockers, such as glinides and sulfonylurea drugs, can induce loss of ischemic preconditioning. This study aimed to investigate the effects of repaglinide, a hypoglycemic agent with an affinity for myocardial ATP-sensitive K (+)channels, on the results of consecutive exercise tests in patients with diabetes and multivessel coronary artery disease. METHODS Forty-two patients with type 2 diabetes and chronic stable angina pectoris, and two-vessel or three-vessel disease participated in this study. The patients underwent two consecutive treadmill exercise tests (phase 1). On the day after these exercise tests, 2 mg of oral repaglinide was given to the patients. One week later, two exercise tests were repeated consecutively (phase 2). RESULTS All patients achieved 1.0-mm ST-segment depression during the four exercise tests (T1, T2, T3, and T4). In phase 2, seven patients improved in time to onset of 1.0-mm ST-segment depression. The worsening of the time to onset of 1.0-mm ST-segment depression in phase 2 demonstrated ischemic preconditioning block in 83.3% of patients (P=0.0001). Even the postexercise electrocardiographic parameters (ST-segment depression morphology and magnitude and arrhythmias) were significantly different between the groups with and without pharmacologic ischemic preconditioning block (P=0.031). CONCLUSIONS Repaglinide, an oral hypoglycemic agent with ATP-sensitive K(+) channel-blocker activity, eliminated the myocardial ischemic preconditioning in patients with coronary disease and diabetes.
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Affiliation(s)
- Whady Hueb
- Heart Institute of the University of São Paulo, São Paulo, Brazil
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24
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Lindhardt TB, Abedini S, Olesen RM, Haunsø S, Gadsbøll N. Effects of pharmacological modulation of the ATP-sensitive potassium channels on the development of warm-up angina pectoris. Cardiology 2005; 105:17-21. [PMID: 16166774 DOI: 10.1159/000088266] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/26/2005] [Accepted: 03/30/2005] [Indexed: 11/19/2022]
Abstract
The aim of this study was to examine the effect of pharmacological modulation of the ATP-sensitive potassium channels in the development of warm-up angina pectoris. Thirty-one patients with stable angina pectoris, a positive exercise test and angiographically documented coronary artery disease underwent three exercise tests 90 min after receiving either glibenclamide 10.5 mg (an ATP-sensitive potassium channel blocker), pinacidil 25 mg (an ATP-sensitive potassium channel opener) or placebo in a blinded fashion. There was a 30-min recovery period between the first and the second test and 60 min between the second and the third test. The rate-pressure product at 1-mm ST-segment depression (ischemic threshold) and the maximum ST-segment depression (STD) adjusted to the highest rate-pressure product common to the three tests were analyzed. In the placebo group, there was a significant increase in the ischemic threshold during the second and third test and a significant decrease in the maximum adjusted STD during the second test which was lost during the third test. This apparent adaptation to exercise-induced ischemia was not seen in the glibenclamide-treated patients. In the pinacidil-treated patients, there was a paradoxical decrease in ischemic threshold during the second test with no change in maximum adjusted STD which tended to be lower than in the placebo-treated patients on each exercise test. This study confirms that the warm-up phenomenon can be induced during repeated exercise testing. The blockade of this phenomenon by glibenclamide suggests that the ATP-sensitive potassium channels may be involved in this potential protective mechanism. At the same time, the paradoxical response in the pinacidil-treated patients flags a warning that drugs acting on the sarcolemmal ATP-sensitive potassium channels may have a direct effect on the ST-segment that may interfere with the interpretation of the electrocardiogram.
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25
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Abstract
Ischemic preconditioning (PC) is a polygenic defensive cellular adaptive phenomenon of the heart to ischemic stress, whereby the heart changes its phenotype to become more resistant to subsequent ischemia. Early and late of PC represent two chronologically and pathophysiologically distinct phases of this phenomenon, which can be recruited pharmacologically. We represent a post hoc analysis examining the late PC-mimetic effects of nitroglycerin (NTG) on peri-procedural myocardial necrosis during percutaneous coronary intervention (PCI). A group of 66 patients presenting with angina were randomized, 24 h prior to a scheduled PCI for single obstructive CAD, to a 4 h pretreatment with intravenous NTG or saline. Measurements of electrocardiographic ST-segment shifts, echocardiographic regional wall motion and angina scores demonstrated that NTG pre-treatment preconditioned the heart by rendering it resistant to ischemia during balloon inflations. NTG-pretreated patients exhibited trends towards lower average peak CK (131.1 vs. 188.6 U/L, P = 0.38) and CK-MB levels (7.1 vs. 12.6 ng/ml, P = 0.40). NTG, however, had no significant impact on the incidence of post-procedural MI or any cardiac enzyme elevation. The exploitation of ischemic and pharmacological PC may prove a useful strategy to confer cardioprotection during high-risk PCI and is worth exploring.
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Affiliation(s)
- Hani Jneid
- Division of Cardiology, the University of Louisville, Louisville, KY 40292, USA
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26
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Ding YH, Young CN, Luan X, Li J, Rafols JA, Clark JC, McAllister JP, Ding Y. Exercise preconditioning ameliorates inflammatory injury in ischemic rats during reperfusion. Acta Neuropathol 2005; 109:237-46. [PMID: 15616790 DOI: 10.1007/s00401-004-0943-y] [Citation(s) in RCA: 87] [Impact Index Per Article: 4.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/09/2004] [Revised: 09/06/2004] [Accepted: 10/13/2004] [Indexed: 10/26/2022]
Abstract
There is evidence that physical activity is associated with decreased brain injury resulting from transient middle cerebral artery (MCA) occlusion. We investigated whether exercise could reduce stroke-induced brain inflammatory injury and its associated mediators. Sprague Dawley rats (3 months old) were subjected to 30 min exercise on a treadmill each day for 1-3 weeks. Stroke, in exercised and non-exercised animals, was then induced by a 2-h MCA occlusion followed by 48 h of reperfusion using an intraluminal filament. Endothelial expression of the intercellular adhesion molecule 1 (ICAM-1) and leukocyte infiltration were determined by immunocytochemistry. Expressions of tumor necrosis factor-alpha (TNF-alpha) and ICAM-1 mRNA were detected using a real-time reverse transcriptase-polymerase chain reaction in ischemic rats with or without exercise, and in non-ischemic control rats following exercise. Expression of TNF-alpha increased after exercise for 2 and 3 weeks. The overexpression of TNF-alpha was not further elevated in 3-week exercised rats subjected to a transient MCA occlusion and 6 or 12 h of reperfusion, as compared to that in non-exercised rats. Furthermore, ICAM-1 mRNA expression remained at significantly (P<0.01) low levels in exercised animals during ischemia/reperfusion. Pre-ischemic exercise significantly (P<0.01) reduced numbers of ICAM-1-positive vessels and infiltrating leukocytes in the frontoparietal cortex and dorsolateral striatum in ischemic rats after 48 h of reperfusion. Exercised ischemic rats demonstrated an 11+/-7% infarct volume of contralateral hemisphere as compared to a 52+/-3% volume in non-exercised ischemic rats. The data suggests that exercise inhibits inflammatory injury (i.e., decreased expression of inflammatory mediators and reduced accumulation of leukocytes) during reperfusion, leading to reduced brain damage. Chronically increased expression of TNF-alpha during exercise prevent the same downstream inflammatory events as does acutely elevated TNF-alpha after ischemia/reperfusion.
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Affiliation(s)
- Yun-Hong Ding
- Department of Neurological Surgery, Wayne State University School of Medicine, Lande Medical Research Building, Room 48, 550 E. Canfield Street, Detroit, MI 48201, USA
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Edwards RJ, Redwood SR, Lambiase PD, Marber MS. The effect of an angiotensin-converting enzyme inhibitor and a K+(ATP) channel opener on warm up angina. Eur Heart J 2004; 26:598-606. [PMID: 15618027 DOI: 10.1093/eurheartj/ehi082] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
Abstract
AIMS In various models, angiotensin-converting enzyme (ACE) inhibitors and K+(ATP) channel openers can potentiate and mimic ischaemic preconditioning, respectively. Our aim was to determine whether these characteristics are shared by the phenomenon of warm up in angina, often regarded as a surrogate of ischaemic preconditioning. METHODS AND RESULTS Twenty patients with ischaemic heart disease were assigned in a double blind, randomized cross-over design to equivalent pressor doses of nicorandil 20 mg bid, enalapril 10 mg bid, losartan 25 mg bid, or placebo for 3 days. Patients underwent three consecutive exercise tolerance tests on each medication separated by a 1-week interval. Each patient underwent 12 exercise tests in total and 13 patients completed the study. On each medication the second exercise was separated from the first by 15 min of rest and the third exercise was performed 90 min after the second to control for training. The time to 0.1 mV ST depression and rate pressure product at 0.1 mV ST depression increased significantly in all groups during exercise two compared with exercise one. Nicorandil reduced angina but did not attenuate this warm up effect. This benefit of first exercise waned by test three with placebo, losartan, and nicorandil, but not with enalapril. CONCLUSION In contrast to predictions based on ischaemic preconditioning the magnitude of the warm up was apparently unaltered by nicorandil, losartan, or enalapril, however its duration seemed to be extended by enalapril. Thus ischaemic preconditioning and warm up angina are likely to have differing pharmacological profiles suggesting a diverse underlying mechanism.
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Affiliation(s)
- Richard J Edwards
- Division of Cardiology, KCL, The Rayne Institute, St Thomas' Hospital, London SE1 7EH, UK
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Ding Y, Li J, Luan X, Ding YH, Lai Q, Rafols JA, Phillis JW, Clark JC, Diaz FG. Exercise pre-conditioning reduces brain damage in ischemic rats that may be associated with regional angiogenesis and cellular overexpression of neurotrophin. Neuroscience 2004; 124:583-91. [PMID: 14980729 DOI: 10.1016/j.neuroscience.2003.12.029] [Citation(s) in RCA: 134] [Impact Index Per Article: 6.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 12/18/2003] [Indexed: 10/26/2022]
Abstract
There is increasing evidence that physical activity is associated with a decreased stroke risk. The purpose of this study was to determine if exercise could also reduce brain damage in rats subjected to transient middle cerebral artery (MCA) occlusion, and if the reduced brain injury is associated with angiogenesis as well as cellular expression of the nerve growth factor (NGF) and brain-derived neurotrophic factor (BDNF) in regions supplied by the MCA. Adult male Sprague Dawley rats (n=36) exercised 30 min each day for 3 weeks on a treadmill on which repetitive locomotor movement was required. Then, stroke was induced by a 2-h MCA occlusion using an intraluminal filament, followed by 48 h of reperfusion. In addition to the two exercised groups of animals with or without MCA occlusion, there were two other groups of animals, with or without MCA occlusion, housed for the same duration and used as non-exercised controls. Brain damage in ischemic rats was evaluated by neurologic deficits and infarct volume. Exercise preconditioned and non-exercised brains were processed for immunocytochemistry to quantify the number of microvessels or NGF- and BDNF-labeled cells. Pre-ischemic motor activity significantly (P<0.01) reduced neurologic deficits and infarct volume in the frontoparietal cortex and dorsolateral striatum. Cellular expressions of NGF and BDNF were significantly (P<0.01) increased in cortex (neuron) and striatum (glia) of rats under the exercise condition. Significant (P<0.01) increases in microvessel density were found in striatum. Physical activity reduced stroke damage. The reduced brain damage may be attributable to angiogenesis and neurotrophin overexpression in brain regions supplied by the MCA following exercise.
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Affiliation(s)
- Y Ding
- Department of Neurological Surgery, Wayne State University School of Medicine, Lande Medical Research Building, Room 48, 550 East Canfield Street, Detroit, MI 48201, USA.
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Affiliation(s)
- G Alec Rooke
- University of Washington and Veterans Affairs Puget Sound Health Care System, Seattle, Washington 98108, USA.
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Michaelides AP, Andrikopoulos GK, Oikonomou EV, Psomadaki ZD, Richter DJ, Dilaveris PE, Exadaktylos NI, Stefanadis CI, Toutouzas PK. Improved myocardial performance during repetitive exercise testing: the role of extracellular superoxide dismutase activity in a model of exercise-induced myocardial preconditioning. Am Heart J 2003; 146:160-7. [PMID: 12851626 DOI: 10.1016/s0002-8703(03)00115-7] [Citation(s) in RCA: 15] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/20/2022]
Abstract
BACKGROUND The aim of this study was to investigate whether endogenous antioxidant defense is involved in adaptation to myocardial ischemia in patients with coronary artery disease and severe exercise-induced myocardial ischemia. METHODS Fifty patients, aged 50 to 72 years (mean, 58 +/- 6 years), with positive exercise test results underwent 4 treadmill exercise tests. Thallium-201 scintigraphy was performed during the first and the fourth testing. The second, the third, and the fourth tests were performed the next day. The time interval between the second and the third test was 15 minutes, and between the third and the fourth test, the interval was 45 minutes. Extracellular superoxide dismutase activity was measured just before and at the peak of the first and the fourth exercise test. RESULTS The patients were divided in 2 groups according to the extent of myocardial ischemia at peak exercise of the fourth test compared with the first test. Most of the patients studied (37/50) showed improved myocardial performance during the last of the sequential exercise tests, as demonstrated with the studied exercise parameters and the extent of myocardial ischemia in thallium-scintigraphy. Extracellular superoxide dismutase activity before the last exercise test was found to be significantly increased only in the patients who had improved myocardial performance at the last of the sequential exercise tests. CONCLUSION The beneficial effects of sequential episodes of exercise-induced myocardial ischemia seem to be strongly related to extracellular superoxide dismutase activity. Although there is still lack of direct evidence, our data support the theory that the favorable adaptation to repetitive exercise may represent an aspect of the clinical relevance of ischemic preconditioning in humans.
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Affiliation(s)
- Andreas P Michaelides
- Exercise Laboratory, Cardiac Department of Athens University, Hippokration Hospital, Athens, Greece.
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Bogaty P, Poirier P, Boyer L, Jobin J, Dagenais GR. What induces the warm-up ischemia/angina phenomenon: exercise or myocardial ischemia? Circulation 2003; 107:1858-63. [PMID: 12665486 DOI: 10.1161/01.cir.0000060545.09308.f5] [Citation(s) in RCA: 19] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
BACKGROUND The relation of the warm-up ischemia phenomenon to the presence and intensity of initial myocardial ischemia is unclear. We sought to determine whether the warm-up ischemia phenomenon requires initial myocardial ischemia or can be induced by exercise without ischemia and whether there is a relation between the intensity of initial ischemia and the attenuation of ischemia on reexercise. METHODS AND RESULTS Twelve subjects with exertional myocardial ischemia performed 2 exercise ECG tests (1 and 2) at a +/-10-minute interval on 3 occasions (A, B, C) 1 month apart. A1 and A2 were symptom-limited. B1 was kept as long as A1, but its intensity was held under the ischemic threshold (heart ratexsystolic pressure at 1-mm ST depression [STD]) noted at A1. B2 was symptom-limited. C1 was also kept as long as A1 but with an intensity adjusted to maintain one-half maximum STD of A1. C2 was symptom-limited. Exercise duration of A2, B2, and C2 increased similarly compared with A1 (P=0.009). However, the ischemic threshold (x10-3) increased at A2 (23.5+/-6.0) compared with A1 (20.3+/-4.8; P<0.0001) but not at B2 (19.8+/-5.0) or C2 (21.5+/-5.8). Similarly, maximum STD adjusted to the highest heart rate-systolic pressure product common to A1, A2, B2, and C2 decreased at A2 (1.4+/-0.7 mm) compared with A1 (2.5+/-0.9 mm; P<0.0001) but not at B2 (2.7+/-0.9 mm) or C2 (2.3+/-0.9 mm). CONCLUSIONS Exercises under the ischemic threshold and of intermediate ischemic intensity increase short-term exercise capacity, but myocardial ischemia of more than moderate intensity is needed to induce the warm-up ischemia phenomenon.
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Affiliation(s)
- Peter Bogaty
- Quebec Heart Institute/Laval Hospital, 2725 Chemin Ste-Foy, Ste-Foy, Quebec, Canada G1V 4G5.
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Scognamiglio R, Avogaro A, Vigili de Kreutzenberg S, Negut C, Palisi M, Bagolin E, Tiengo A. Effects of treatment with sulfonylurea drugs or insulin on ischemia-induced myocardial dysfunction in type 2 diabetes. Diabetes 2002; 51:808-12. [PMID: 11872684 DOI: 10.2337/diabetes.51.3.808] [Citation(s) in RCA: 71] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/13/2022]
Abstract
In patients with diabetes and coronary artery disease, the potential negative role of sulfonylurea drugs is under intensive investigation. We assessed the effects of treatment with glibenclamide or insulin on the extension of left ventricular myocardial dysfunction induced by acute ischemia. Nineteen consecutive patients with type 2 diabetes and coronary artery disease entered the study. Each patient was randomly assigned to either insulin or glibenclamide therapy. Treatment was crossed over after 12 weeks and maintained for another 12 weeks. At the end of each treatment, left ventricular myocardial function at rest and during dipyridamole infusion was studied by two-dimensional echocardiography under the same conditions of metabolic control. Glibenclamide or insulin treatment did not influence the rest values of left ventricular dimensions, left ventricular ejection fraction (LVEF), or wall motion score index (WMSI). Dipyridamole infusion, in patients receiving glibenclamide treatment, decreased LVEF (43 +/- 7 vs. 37 +/- 12%, P < 0.005) and increased WMSI (1.4 +/- 0.28 vs. 1.98 +/- 0.24, P < 0.001) compared with baseline values; during insulin treatment, LVEF (46 +/- 8 vs. 45 +/- 11%, NS) and WMSI (1.4 +/- 0.29 vs. 1.6 +/- 0.4, NS) did not change significantly. Peak stress LVEF was higher (45 +/- 11 vs. 37 +/- 12%, P < 0.001) and WMSI lower (1.6 +/- 0.4 vs. 1.98 +/- 0.24, P < 0.001) in patients receiving insulin. The results indicate that in patients with type 2 diabetes and coronary artery disease, ischemic myocardial dysfunction induced by dipyridamole infusion is less severe during treatment with insulin than with glibenclamide. Restitution of a preconditioning mechanism in insulin-treated patients may be the potential beneficial mechanism.
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Affiliation(s)
- Roldano Scognamiglio
- Division of Cardiology, Department of Clinical and Experimental Medicine, University of Padua Medical School, Padua, Italy.
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Bogaty P, Kingma JG, Guimond J, Poirier P, Boyer L, Charbonneau L, Dagenais GR. Myocardial perfusion imaging findings and the role of adenosine in the warm-up angina phenomenon. J Am Coll Cardiol 2001; 37:463-9. [PMID: 11216964 DOI: 10.1016/s0735-1097(00)01154-2] [Citation(s) in RCA: 17] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/18/2022]
Abstract
OBJECTIVES This study examined the roles of myocardial perfusion and adenosine in warm-up angina. BACKGROUND In warm-up angina, neither the role of an adenosine-mediated mechanism, as is found in experimental ischemic preconditioning, nor of increased myocardial perfusion is well defined. METHODS In substudy A, a single-photon emission computed tomography (SPECT)-thallium-201 exercise test was performed by 12 subjects with ischemic heart disease on three occasions one week apart. The third test was preceded by a warm-up test. The extent of the thallium deficit and its intensity on the third test were compared with the baseline tests controlling for the heart rate-systolic blood pressure product (RPP) at thallium injection. In substudy B, 12 similar subjects did two successive exercise tests at two separate sessions and received the adenosine antagonist, aminophylline (intravenous 5 mg/kg bolus and 0.9 mg/kg/h infusion) at one session, and equivalent saline at the other session. Change in ischemic threshold (RPP at 1 mm ST segment depression) and in maximum ST depression adjusted for RPP were analyzed. RESULTS In substudy A, despite a significant attenuation of electrocardiogram indexes of myocardial ischemia between the baseline and third (warmed-up) tests, the thallium extent deficits (20.8 +/- 15.1% and 16.8 +/- 12.4%) and intensity deficits (41.2 +/- 12.6% and 39.3 +/- 12.6%) did not differ significantly. In substudy B, the increase in ischemic threshold on re-exercise was unaffected by aminophylline. Adjusted maximum ST depression even decreased to a greater extent on re-exercise with aminophylline (by 51 +/- 21%) than with saline (by 32 +/- 19%) (p = 0.012). CONCLUSIONS While warm-up angina is associated with a significant attenuation of exercise electrocardiogram indexes of ischemia, it is unaccompanied by significant changes in SPECT perfusion and does not appear to be mediated by an adenosine-dependent mechanism since it is not blocked by aminophylline. Thus, its mechanism, which appears distinct from experimental ischemic preconditioning, remains unidentified.
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Affiliation(s)
- P Bogaty
- Quebec Heart Institute/Laval Hospital, Laval University, Sainte-Foy, Canada.
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Napoli C, Pinto A, Cirino G. Pharmacological modulation, preclinical studies, and new clinical features of myocardial ischemic preconditioning. Pharmacol Ther 2000; 88:311-31. [PMID: 11337029 DOI: 10.1016/s0163-7258(00)00093-0] [Citation(s) in RCA: 23] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/19/2022]
Abstract
The term "ischemic preconditioning (PC)" was first applied to canine myocardium subjected to brief episodes of ischemia and reperfusion that tolerated a more prolonged episode of ischemia better than myocardium not previously exposed to ischemia. Protective effect of myocardial ischemic PC was demonstrated in several animal species, resulting in the strongest endogenous form of protection against myocardial injury, jeopardized myocardium, infarct size, and arrhythmias other than early reperfusion. New onset angina before acute myocardial infarction, episodes of myocardial ischemia during coronary angioplasty or bypass surgery, and the "warm-up" phenomenon may represent clinical counterparts of the PC phenomenon in humans. Here, we have attempted to summarize pharmacological modulation, preclinical studies, and new clinical features of ischemic PC. To date, the pathophysiological basis of the "chemical PC" is still not well established, and "putting PC in a bottle" for clinical applications still remains a new pharmacological venture.
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Affiliation(s)
- C Napoli
- Department of Medicine, Federico II University of Naples, P.O. Box, Naples 80131, Italy.
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Edwards RJ, Saurin AT, Rakhit RD, Marber MS. Therapeutic potential of ischaemic preconditioning. Br J Clin Pharmacol 2000; 50:87-97. [PMID: 10930960 PMCID: PMC2014394 DOI: 10.1046/j.1365-2125.2000.00236.x] [Citation(s) in RCA: 22] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/11/2000] [Accepted: 04/26/2000] [Indexed: 12/13/2022] Open
Affiliation(s)
- R J Edwards
- Department of Cardiology, KCL, St Thomas' Hospital, London SE1
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Ovünç K. Effects of glibenclamide, a K(ATP) channel blocker, on warm-up phenomenon in type II diabetic patients with chronic stable angina pectoris. Clin Cardiol 2000; 23:535-9. [PMID: 10894443 PMCID: PMC6654987 DOI: 10.1002/clc.4960230713] [Citation(s) in RCA: 42] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/18/1999] [Accepted: 09/29/1999] [Indexed: 11/08/2022] Open
Abstract
BACKGROUND Warm-up phenomenon, one of the clinical models of ischemic preconditioning, refers to an increased tolerance to myocardial ischemia during the second of two consecutive exercise tests. HYPOTHESIS Blockers of K(ATP) channels, such as the sulfonylurea drugs, can induce loss of ischemic preconditioning. This study aimed to investigate the effects of glibenclamide, a sulfonylurea with a high affinity for myocardial K(ATP) channels, on the results of two consecutive exercise tests in diabetic patients with coronary artery disease. METHODS Eighteen type II diabetic patients with chronic stable angina pectoris participated in this study. All patients underwent two consecutive treadmill exercise tests with a recovery period of 15 min in fasting state. On the day after these exercise tests, 10 mg oral glibenclamide was given to the same patients and 30 min later 200 ml of 30% glucose solution was given orally. Half an hour later, which is the time of peak plasma levels of glibenclamide, two exercise tests were repeated consecutively with a 15 min recovery period. RESULTS There was no difference in blood glucose levels before and after exercise tests on each day (p > 0.05). Without glibenclamide, heart rate, rate-pressure product at 1.5 mm ST depression, and peak exercise increased significantly (p < 0.05). Time to 1.5 mm ST-segment depression and onset of pain, as well as duration of exercise also increased, but ST-segment depression and ST-recovery time significantly decreased (p < 0.05). In contrast, these values did not significantly change after glibenclamide (p>0.05), with a significant drug-test interaction (p < 0.05, at two-way ANOVA). CONCLUSIONS Glibenclamide, an oral hypoglycemic agent with a K(ATP) channel-blocker activity, with a 10 mg oral dose, abolished the warm-up phenomenon which is a clinical finding of ischemic preconditioning on two consecutive exercise tests. Therefore, glibenclamide should be used carefully in patients with coronary heart disease and diabetes mellitus since this agent leads to a decrease in ischemic threshold and exercise capacity.
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Affiliation(s)
- K Ovünç
- Hacettepe University, Faculty of Medicine, Department of Cardiology, Ankara, Turkey
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Kay IP, Kittelson J, Stewart RA. Collateral recruitment and "warm-up" after first exercise in ischemic heart disease. Am Heart J 2000; 140:121-5. [PMID: 10874272 DOI: 10.1067/mhj.2000.106644] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/22/2022]
Abstract
BACKGROUND Proposed mechanisms for "warm-up" after angina on first exercise include ischemic preconditioning and collateral recruitment. The aim of this study was to determine whether patients with ischemic heart disease and well-developed coronary collateral vessels have a greater warm-up response than those with no visible collateral vessels. METHODS AND RESULTS Fifteen patients with a total coronary occlusion and collateral vessels and 18 patients with a single coronary artery stenosis and no angiographically visible collateral vessels were studied. Warm-up was measured as the difference in ST depression on the second compared with the first of 2 sequential treadmill exercise tests separated by 10 minutes of rest. There was a trend for the duration of second exercise to increase more in patients with occlusion than in those with stenosis (+1.3 vs +0.54 minutes, respectively, P =.087). In both groups, ST depression was less on second exercise than on first exercise. The size of this decrease was greater in the occlusion group than in the stenosis group. ST depression at equivalent submaximal exercise decreased by 0.52 vs 0.19 mm, respectively (P =.049). The rate of increase in ST depression during exercise decreased by 1.08 versus 0. 55 mm/min, respectively (P =.034). These differences were less after adjustment for ST depression on first exercise (P =.11 and P =.063, respectively). CONCLUSIONS The trend for a greater decrease in ST depression on second compared with first exercise in the patients with total coronary occlusion suggests that an increase in collateral flow is a mechanism for warm-up after first exercise in ischemic heart disease.
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Affiliation(s)
- I P Kay
- Department of Medicine, University of Otago, Dunedin, New Zealand
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Radák Z, Sasvári M, Nyakas C, Pucsok J, Nakamoto H, Goto S. Exercise preconditioning against hydrogen peroxide-induced oxidative damage in proteins of rat myocardium. Arch Biochem Biophys 2000; 376:248-51. [PMID: 10775409 DOI: 10.1006/abbi.2000.1719] [Citation(s) in RCA: 61] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/22/2022]
Abstract
Both regular physical exercise and low levels of H(2)O(2) administration result in increased resistance to oxidative stress. We measured the accumulation of reactive carbonyl derivatives and the activities of proteasome complex and DT-diaphorase in cardiac muscle of trained and untrained rats after chronic i.p. administration of 1 ml t-butyl H(2)O(2) (1 mmol/kg for 3 weeks every second day). Twenty-four rats were randomly assigned to a control group administered with saline, control administered with H(2)O(2), and exercised administered either saline or H(2)O(2). The activity of DT-diaphorase significantly increased in H(2)O(2) administered and exercised groups, indicating that an increase in H(2)O(2) levels stimulate the activity of this enzyme. The cardiac muscle of H(2)O(2) administered nonexercised animals accumulated significantly more carbonyl than control group (P < 0.05). The exercise and H(2)O(2) administration resulted in less oxidatively modified protein than found in nonexercised groups (P < 0.05). The peptide-like activity of proteasome complex was induced by the treatment of H(2)O(2) and exercise and exercise potentiate the effect of H(2)O(2). On the other hand, the chymotrypsin-like and trypsin-like activities were stimulated only by physical training and H(2)O(2) administration. The data suggest that chronic administration of H(2)O(2) after exercise training decreases the accumulation of carbonyl groups below the steady-state level and induces the activity of proteasome and DT-diaphorase. Hence, the stimulating effect of physical exercise on free radical generation is an important phenomenon of the exercise-induced adaptation process since it increases resistance to oxidative stress. Regular exercise training is a valuable physiological means of preconditioning the myocardium to prolonged oxidative stress.
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Affiliation(s)
- Z Radák
- Laboratory of Exercise Physiology, Semmelweis University, Budapest, Hungary
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Longobardi G, Abete P, Ferrara N, Papa A, Rosiello R, Furgi G, Calabrese C, Cacciatore F, Rengo F. "Warm-up" phenomenon in adult and elderly patients with coronary artery disease: further evidence of the loss of "ischemic preconditioning" in the aging heart. J Gerontol A Biol Sci Med Sci 2000; 55:M124-9. [PMID: 10795723 DOI: 10.1093/gerona/55.3.m124] [Citation(s) in RCA: 34] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
Abstract
BACKGROUND A reduction of exercise-induced ischemia in patients with coronary artery disease by means of brief period of exercise followed by resting is called the "warm-up" phenomenon. This phenomenon may represent a clinical counterpart of "ischemic preconditioning." We studied the warm-up phenomenon in both adult and elderly patients with similar angiographic evidence of coronary artery disease, using three exercise tests after excluding the "training effect." METHODS In order to verify the presence of "training effect," three exercise tests were performed in days 1, 2, and 3 ("training" tests). The third test was used as baseline for a successive test, performed after a recovery period of 10 minutes to reestablish baseline electrocardiographic conditions. A third exercise test was performed 30 minutes later ("warm-up" tests). RESULTS "Training" tests did not differ in all parameters in both adult and elderly patients. "Warm-up" tests showed that time to onset 1-mm ST depression was significantly higher (p < .001). whereas ST depression and time to recovery was significantly lower in the second and third test in adult but not in elderly patients (p < .001 ). Difference (in seconds) in the time at which 1-mm ST depression occurred on first warm-up exercise compared with the second was inversely correlated with age (p < .001 ). CONCLUSIONS Previous exercise followed by resting is able to reduce the successive exercise-induced ischemia ("warm-up" phenomenon) in adult but not in elderly patients with coronary artery disease. This is independent of a greater age-related severity of coronary disease and of "training effect." These results confirm the hypothetical age-related reduction of "ischemic preconditioning" in aging heart.
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Affiliation(s)
- G Longobardi
- Fondazione Salvatore Maugeri--IRCCS, Centro Medico di Telese Terme, Benevento, Italy.
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Kay P, Kittelson J, Stewart RA. Relation between duration and intensity of first exercise and "warm up" in ischaemic heart disease. Heart 2000; 83:17-21. [PMID: 10618328 PMCID: PMC1729284 DOI: 10.1136/heart.83.1.17] [Citation(s) in RCA: 15] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/03/2022] Open
Abstract
OBJECTIVE To determine the importance of the duration and intensity of "warm up" exercise for reducing ischaemia during second exercise in patients with exertional angina. DESIGN Randomised crossover comparison of three warm up exercise protocols. PATIENTS 18 subjects with stable ischaemic heart disease and > 0.1 mV ST segment depression on treadmill exercise testing. INTERVENTIONS The warm up protocols were 20 minutes of slow exercise at 2.7 km/h, symptom limited graded exercise for a mean of 7.4 (range 5.0 to 10.5) minutes, and three minutes of symptom limited fast exercise of similar maximum intensity. MAIN OUTCOME MEASURES ST segment depression during graded treadmill exercise undertaken 10 minutes after each warm up protocol or no warm up exercise. RESULTS Compared with exercise with no warm up, the duration of graded exercise after earlier slow warm up increased by 4.9% (95% confidence interval (CI), -3.3% to 13.7%), after graded warm up by 10.3% (95% CI, 5.6% to 15.2%), and after fast warm up by 16% (95% CI, 6.2% to 26.7%). ST segment depression at equivalent submaximal exercise decreased after slow warm up by 27% (95% CI, 5% to 44%), after graded warm up by 31% (95% CI, 17% to 44%), and after fast warm up by 47% (95% CI, 27% to 61%). Compared with slow warm up exercise, the more intense graded and fast warm up protocols significantly increased the duration of second exercise (p = 0.0072) and reduced both peak ST depression (p = 0.0026) and the rate of increase of ST depression (p = 0.0069). CONCLUSIONS In patients with exertional angina the size of the warm up response is related to the maximum intensity rather than the duration of first exercise.
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Affiliation(s)
- P Kay
- Department of Medicine, University of Otago, Dunedin, New Zealand
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Napoli C, Liguori A, Cacciatore F, Rengo F, Ambrosio G, Abete P. "Warm-up" phenomenon detected by electrocardiographic ambulatory monitoring in adult and older patients. J Am Geriatr Soc 1999; 47:1114-7. [PMID: 10484256 DOI: 10.1111/j.1532-5415.1999.tb05237.x] [Citation(s) in RCA: 18] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
Abstract
OBJECTIVE Inducing tolerance to myocardial ischemia by repeated brief episodes of ischemia has been called "ischemic preconditioning." "Warm-up" phenomenon refers to patients with coronary heart disease improving performance after a first exertion and may represent a clinical counterpart to ischemic preconditioning. The goal of this study was to assess whether the severity of myocardial ischemia would be attenuated by two repeated walking-induced ischemic episodes in adult and older patients. SUBJECTS Thirty-eight adults (51 +/- 5 years) and 39 older patients (76 +/- 4 years) with stable angina and angiographic evidence of coronary stenosis. MEASUREMENTS Holter monitoring was performed in adult and older patients walking on two consecutive occasions, with a 5-minute rest between walks, a distance known to have previously caused myocardial ischemia. RESULTS Computer-assisted analysis recorded by ambulatory Holter monitoring revealed that the mean maximal ST-segment depression (P < .001) and ischemia duration decreased (P < .001), whereas the ischemic threshold increased (P < .001), from the first to the second walk in the adult but not in the older group. CONCLUSIONS Myocardial ischemia is attenuated and ischemic threshold is increased between two brief ischemic episodes in adult but not in older patients. These results indicate that the "warm-up" phenomenon, involved in increasing myocardial ischemic tolerance, is absent in the aging heart.
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Affiliation(s)
- C Napoli
- Dipartimento di Medicina Clinica e Sperimentale, Facoltà di Medicina e Chirurgia, Università degli Studi di Napoli Federico II, Naples, Italy
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Grund F, Sommerschild HT, Lyberg T, Kirkeboen KA, Ilebekk A. Microembolization in pigs: effects on coronary blood flow and myocardial ischemic tolerance. THE AMERICAN JOURNAL OF PHYSIOLOGY 1999; 277:H533-42. [PMID: 10444478 DOI: 10.1152/ajpheart.1999.277.2.h533] [Citation(s) in RCA: 22] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/22/2022]
Abstract
Coronary microembolization has been reported to increase coronary blood flow (CBF) through adenosine release. Because adenosine may increase ischemic tolerance against infarction, we tested the hypothesis that myocardial microembolization, a common finding in patients with ischemic heart disease, induces cardioprotection. Additionally, because the use of microspheres is a common tool to measure tissue perfusion, the effects of small amounts of microspheres on CBF were examined. Using anesthetized pigs, we measured CBF with a transit time flow probe on the left anterior descending coronary artery (LAD). In six pigs the relationship between the amount of injected microspheres (0-40 x 10(6), 15 micrometer in diameter, left atrial injections) and the effect on CBF was examined. Coronary hyperemia occurred, which was linearly related to the amount of microspheres injected: maximal increase in CBF (%) = 2.8 +/- 1.5 (SE) + (5.8 +/- 0.7 x 10(-7) x number of injected microspheres). Because injection of 40 x 10(6) microspheres induced a long-lasting hyperemic response, which could be blocked by 8-p-sulfophenyl theophylline, ischemic tolerance was examined in five other pigs after two injections, each of 40 x 10(6) microspheres, at a 30-min interval. Six control pigs had no injections. Ischemic tolerance was evaluated by measuring infarct size (tetrazolium stain) as the percentage of area at risk (fluorescent particles) after 45 min of LAD occlusion followed by 2 h of reperfusion. Pretreatment by microspheres increased infarct size from 60 +/- 3% of area at risk in control animals to 84 +/- 6% (P < 0.05). The injection of microspheres induced a significant hyperemic flow response without causing necrosis by itself. We conclude that microembolization, evoking coronary hyperemia, does not improve but reduces myocardial ischemic tolerance against infarction in pigs.
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Affiliation(s)
- F Grund
- Institute for Experimental Medical Research, University of Oslo, Ullevâl Hospital, N-0407 Oslo, Norway.
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Tomai F, Perino M, Ghini AS, Crea F, Gaspardone A, Versaci F, Chiariello L, Gioffrè PA. Exercise-induced myocardial ischemia triggers the early phase of preconditioning but not the late phase. Am J Cardiol 1999; 83:586-8, A7-8. [PMID: 10073866 DOI: 10.1016/s0002-9149(98)00918-7] [Citation(s) in RCA: 19] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
Abstract
The aim of the present study was to establish whether exercise-induced ischemia triggers the second window of protection in 15 patients with coronary artery disease undergoing 2 consecutive treadmill exercise tests and a third test 24 hours later. Our findings confirm that a first exercise-induced ischemic challenge induces the early phase of preconditioning but not the late phase, thus suggesting that either a late protective effect of preconditioning does not exist in the setting of demand ischemia or, if it exists, it must be weaker than the early protective effect.
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Affiliation(s)
- F Tomai
- Divisione di Cardiochirurgia, Università di Roma Tor Vergata, European Hospital, Rome, Italy
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Bogaty P, Kingma JG, Robitaille NM, Plante S, Simard S, Charbonneau L, Dumesnil JG. Attenuation of myocardial ischemia with repeated exercise in subjects with chronic stable angina: relation to myocardial contractility, intensity of exercise and the adenosine triphosphate-sensitive potassium channel. J Am Coll Cardiol 1998; 32:1665-71. [PMID: 9822094 DOI: 10.1016/s0735-1097(98)00431-8] [Citation(s) in RCA: 30] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
Abstract
OBJECTIVES This study characterized the attenuation of myocardial ischemia observed with re-exercise to determine whether: 1) a differing exercise intensity modifies this attenuation; 2) it could be explained by contractile down-regulation or stunning; 3) it is mediated by activation of ATP-sensitive potassium channels (K+-ATP). BACKGROUND Subjects with ischemic heart disease (IHD) frequently note less angina with re-exercise after a brief rest. Potential mechanisms of this 'warm-up' phenomenon have been little explored. METHODS IHD subjects with a positive exercise test were studied. Groups I and II (12 subjects each) underwent 2 successive Naughton protocol exercise echocardiography tests (with 1 min instead of 2 min stages for Group II). Group D (10 subjects) had type II diabetes, were on > or =10 mg daily of the K+-ATP blocker, glibenclamide, and underwent the group I exercise protocol. The ischemic threshold or rate-pressure product at 1 mm ST segment depression, ST depression corresponding to the peak rate-pressure product of the first exercise (maximum ST depression equivalent), and left ventricular wall motion indexes before and immediately after each exercise were analyzed. RESULTS Exercise-induced myocardial ischemia with re-exercise was similarly attenuated in groups I, II, and D. The ischemic threshold was raised by nearly 20% with re-exercise (p=0.001, p=0.02, and p=0.02, respectively) and the maximum ST depression equivalent was nearly halved on re-exercise (p=0.005, p=0.006, and p=0.001, respectively). Exercise-induced wall motion dysfunction was attenuated with re-exercise. In group I, wall motion returned to the initial baseline score prior to exercise 2, whereas in the more intense protocol of group II, wall motion dysfunction persisted prior to exercise 2. CONCLUSIONS Thus, the attenuation of myocardial ischemia observed with re-exercise appears to be independent of the intensity of the exercise protocol and is not explained by down-regulation of myocardial contractility induced by the initial ischemic stimulus. Since results were similar in diabetic subjects on robust doses of glibenclamide, this phenomenon does not appear to be mediated by K+-ATP activation.
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Affiliation(s)
- P Bogaty
- Quebec Heart Institute/Laval Hospital, Laval University, Ste-Foy, Canada.
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Protection Conferred by Preinfarct Angina is Manifest in the Aged Heart: Evidence from the TIMI 4 Trial. J Thromb Thrombolysis 1998; 6:89-92. [PMID: 10751789 DOI: 10.1023/a:1008833101817] [Citation(s) in RCA: 40] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/12/2022]
Abstract
There has been debate regarding the issue of whether ischemic preconditioning is effective in the aging and diseased heart. Therefore, we retrospectively analyzed the effect of preinfarction angina in patients less than versus greater than 60 years of age in the TIMI 4 study. Preinfarction angina was defined as an episode of typical angina pectoris that occurs prior to the time of index chest pain associated with the myocardial infarction itself. Patients who were 60 years and older had a higher rate of death and the combined endpoints of death, heart failure/shock, and/or reinfarction compared with younger patients. However, patients 60 years or older who had preinfarction angina had lower rates of the combined endpoints of death, heart failure/shock, and/or reinfarction (11%) compared with patients without angina (23%; P = 0.04). They also had lower creatine kinase (CK) values. Therefore, preinfarction angina was protective in patients 60 years or older in the TIMI 4 study.
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Kloner RA, Bolli R, Marban E, Reinlib L, Braunwald E. Medical and cellular implications of stunning, hibernation, and preconditioning: an NHLBI workshop. Circulation 1998; 97:1848-67. [PMID: 9603540 DOI: 10.1161/01.cir.97.18.1848] [Citation(s) in RCA: 291] [Impact Index Per Article: 11.2] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Affiliation(s)
- R A Kloner
- Heart Institute, Good Samaritan Hospital, and University of Southern California, Los Angeles 90017, USA
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Abstract
Brief transient episodes of nonlethal myocardial ischemia protect or "precondition" the heart and render the myocardium resistant to a subsequent more sustained ischemic insult. The hallmark of this phenomenon--documented in virtually all species and experimental models evaluated to date in countless laboratories worldwide--is the profound reduction in infarct size seen in preconditioned groups versus time-matched controls. Efforts to identify the cellular mechanisms responsible for this paradoxical ischemia-induced cardioprotection, to expand the definition of ischemic preconditioning beyond infarct size reduction, and, perhaps most importantly, to evaluate the efficacy of preconditioning in disease models and in the clinical setting, are all topics of intensive ongoing investigation.
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Affiliation(s)
- K Przyklenk
- Heart Institute, Good Samaritan Hospital and Department of Medicine, University of Southern California, Los Angeles 90017-2395, USA
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Abstract
Myocardial ischemia and infarction are associated with substantially increased morbidity and mortality among patients with diabetes mellitus. Although many factors contribute to the increased morbidity and mortality, in patients with non-insulin-dependent (type II) diabetes mellitus, one contributor may be the use of sulfonylurea drugs, the most widely used oral hypoglycemic agents. Such a possibility, which first arose over a 25 years ago when it was observed that patients taking sulfonylurea drugs had increased cardiovascular mortality, has recently resurfaced after the discovery that sulfonylureas act by inhibiting adenosine triphosphate (ATP)-sensitive potassium channels. In the pancreas, inhibition of ATP-sensitive potassium channels induces release of insulin; but in the heart, inhibition of these channels prevents ischemic preconditioning, an endogenous cardioprotective mechanism that protects the heart from lethal injury. This review outlines the current understanding of the molecular and cellular pharmacodynamics of sulfonylurea drugs and discusses the potential clinical consequences of inhibition of ATP-sensitive potassium channels in the heart of diabetic patients with cardiac disease in whom the use of sulfonylureas may be harmful.
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Affiliation(s)
- P A Brady
- Department of Medicine, Mayo Clinic, Mayo Foundation, Rochester, Minnesota 55905, USA
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Lupi A, Lanza GA, Lucente M, Crea F, Proietti I, Maseri A. The "warm-up" phenomenon occurs in patients with chronic stable angina but not in patients with syndrome X. Am J Cardiol 1998; 81:123-7. [PMID: 9591891 DOI: 10.1016/s0002-9149(97)00886-2] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Abstract
Most patients with chronic stable angina show an improvement in ischemic threshold when a second exercise test is performed a few minutes after a first positive test. In this study we evaluated whether this "warm-up" phenomenon also occurs in patients with syndrome X. We performed 2 consecutive exercise tests in 14 patients with chronic stable angina and 11 patients with syndrome X. The second exercise test was performed after 10 minutes from the end of the first one, always after complete recovery to baseline of ST segment. In patients with stable angina, heart rate (108+/-18 vs 99+/-16 beats/min, p = 0.005), rate-pressure product (17,020+/-4,541 vs 15,215+/-3,734 beats/min x mm Hg, p = 0.028), and exercise time (587+/-297 vs 444+/-244 seconds, p = 0.002) at 1-mm ST depression were higher in the second test than in the first one and a significant improvement in these parameters during the second test was also observed at peak exercise. Conversely, in patients with syndrome X, there were no significant differences between the 2 tests in heart rate (128+/-18 vs 131+/-23 beats/min), rate-pressure product (19,922+/-5,153 vs 19,390+/-5,654 beats/min x mm Hg), and exercise time (592+/-243 vs 566+/-228 seconds) at 1-mm ST-segment depression. Similarly, in this group of patients, no significant differences in exercise variables between the 2 tests were observed at peak exercise. Thus, unlike patients with chronic stable angina, patients with syndrome X have no evidence of warm-up in response to repeated exercise testing.
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Affiliation(s)
- A Lupi
- Istituto di Cardiologia, Università Cattolica del S. Cuore, Rome, Italy
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Abstract
OBJECTIVES The purpose of this study was to assess whether the severity of myocardial ischemia would be attenuated by repeated daily ischemic episodes, recorded by ambulatory electrocardiographic monitoring (AEM). BACKGROUND Repetitive ischemic episodes induced by brief coronary occlusions in animal experiments and in humans during balloon coronary angioplasty produce preconditioning. We wanted to assess whether this phenomenon also exists during daily ischemic episodes. METHODS Twenty-one patients with known coronary artery disease and ischemia on exercise testing and AEM were requested to walk a distance known to have previously caused myocardial ischemia on three consecutive occasions. Walking time was approximately 15 min and was followed by 5 min of rest. RESULTS Mean maximal heart rate during the three walks was similar; however, the mean maximal ST segment depression decreased significantly from 2.21 mm during the first walk to 1.61 mm and 1.43 mm, respectively, on the second and third walks (p = 0.001). Ischemia duration was also significantly reduced on the second and third walks by 56% from 514 to 228 and 254 s, respectively (p = 0.012). The heart rate at onset of ischemia (ischemic threshold) increased from 99 beats/min on the first walk to 101 beats/min on the second walk and to 106 beats/min on the third walk (p = 0.058). CONCLUSIONS This study demonstrated attenuation of myocardial ischemia with an associated increase in ischemic threshold in patients with repeated and adjacent ischemic episodes. This form of myocardial protection is likely to be encountered in patients during ordinary activity and may represent the clinical counterpart of myocardial preconditioning.
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Affiliation(s)
- D Tzivoni
- Jesselson Heart Center, Shaare Zedek Medical Center, Jerusalem, Israel
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